6. Diabetes Flashcards
The pancreas is damaged, and the beta cells don’t produce enough insulin. (Immunologic etiology)
Type 1 diabetes mellitus
The body is unable to recognize the insulin produced by the pancreas and use it properly (insulin resistance). Increased beta cell insulin secretion may initially compensate, but over time, beta cells fail.
Type 2 diabetes mellitus
can develop diabetic ketoacidosis (DKA).
Type 1 DM
(Metabolic gap acidosis associated with a pH
often develop hyperosmolar hyperglycemic state (HHS)
Type 2 DM
Plasma glucose levels are usually >600 mg/dL.
Both HHS and DKA are life-threatening conditions that require prompt management.
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Physical findings of HHS
HHS is characterized by severe dehydration. A profound fluid deficit is usually present, in excess of 9 L on average in adults. Serum osmolality usually exceeds 320 mOsm/kg. Fluid replacement is a key component of treatment.
Precipitants of HHS
Infections, like pneumonia and urinary tract infections, accompanied by a decreased fluid intake are the most common underlying causes of HHS. Other acute conditions like stroke, MI or pulmonary embolism may also precipitate HHS.
In the absence of risk factors, screening for DM should begin at what age?
45
testing should be repeated at least at three-year intervals
Diagnostic Criteria for Diabetes Mellitus
- A random glucose of 200 mg/dL or above, plus symptoms of hyperglycemia like polyuria or unexplained weight loss, or hyperglycemic crisis.
- A fasting plasma glucose of greater than or equal to 126 mg/dL.
- A hemoglobin A1C greater than or equal to 6.5%.
physical exam in DM
Examine thyroid for enlargement or masses because thyroid disease can lead to diabetes and hyperlipidemia. Examine eyes for retinopathy, heart and lungs, and check feet for sores, ulcers and sensation
In severe, non-proliferative retinopathy, look for the following findings on fundoscopic exam:
Retinal hemorrhages are dark blots with indistinct borders that indicate partial obstruction and infarction.
Cotton wool spots are white spots with fuzzy borders and they indicate areas of previous infarction. They accompany hemorrhages. Microaneurysms are more punctate dark lesions that indicate vascular dilatation.
Neovascularization is the hallmark of proliferative retinopathy. The growth of new blood vessels is prompted by retinal vessel occlusion and hypoxia.
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testing for loss of protective sensation
Sensory testing with a 10-gram monofilament PLUS any one of the following:
vibration using 128-Hz tuning fork pinprick sensation ankle reflexes (Achilles necessary, but patellar not needed)
Moderate-intensity statin therapy should be initiated or continued for adults 40 to 75 years of age with diabetes mellitus
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High-intensity statin therapy is reasonable for adults 40 to 75 years of age with diabetes mellitus with a ≥ 7.5% estimated 10-year ASCVD risk unless contraindicated
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Lowering patients A1C to
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ADA/EASD Consensus Algorithm for the Management of Type 2 Diabetes
Tier 1 - well validated approach
Step 1: Diagnosis = HbA1C > 6.5% = Lifestyle changes plus Metformin
Step 2: Assessment. (If HbA1C > 8) = Continue lifestyle changes and Metformin + Add either a sulfonylurea (Glyburide, Glipizide (both second generation) or Glimepiride (third generation)) or basal insulin (Insulin Glargine (Lantus) or Insulin Detemir (Levemir) on intermediate-acting insulin (NPH).
Step 3: Reassessment. (If HbA1C > 8) = Continue lifestyle changes and Metformin + add basal insulin or (if already added) intensify insulin regimen. Consider discontinuing sulfonylurea to avoid hypoglycemia.
It is part of the natural progression of type 2 diabetes that beta-cell function declines, and patients need additional medication…insulin…to lower A1c
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Vaccines Recommended for Patients with Diabetes
Influenza vaccine should be provided to patients with diabetes annually.
Pneumococcal polysaccharide vaccine should be provided to all patients with diabetes over 2 years of age
Hepatitis B vaccine should be administered to all unvaccinated adults with diabetes, HIV, other immunocompromising conditions, or liver disease.
Optimal range for blood glucose
fasting blood glucose should be 80 -120 mg/dl
postprandial blood glucose between 1-2 hours after a meal should be
Conditions that contribute to hyperglycemia
Overeating, missing doses of medication, dehydration, infection and illness, and stress
